Abstract
In this chapter the author concentrates on the methodological strengths and pitfalls of clinical case construction, and discusses how the reliability and validity of case formulations can be optimized. By illustrating clear similarities between the materials used in clinical case formulation, and the data collected by qualitative researchers, Vanheule reviews the literature on quality control in qualitative research, and indicates how aspects of it can be used in enhancing the quality of clinical case formulation. Three dimensions are discussed: reflexivity, reliability, and validity. Vanheule indicates how specific clinical formats that professionals often use (e.g., systematic note taking, case discussions with colleagues, personal therapy, supervision) might function as practices that enhance the credibility and confirmability of clinical case formulations.
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Notes
- 1.
In addition, I might add that Freud distinguishes two major components in the symptom: a meaning-related component and a satisfaction-related component. With the meaning-related component, he refers to the idea that behind a specific symptom often lurks a whole story about issues that are either too painful or too difficult to express. Formulated using the distinction between the signifier and the signified, this means that symptoms express a signified that was displaced or could not be articulated otherwise. The symptom itself is a signifier referring to this signified. The signified in question can only be understood by taking the symptom as a signifier and bringing it into dialog with other signifiers. On the other hand, according to Freud the symptom also implies a satisfaction-related component. The symptom affects the person who has the symptom, and in his turmoil it shows itself to be a form of gratification. The satisfaction is excessive, and as a result she cannot recognize it. Psychoanalytic theory on this satisfaction-related component of the symptom is complex, but an example can lift a tip of the veil. When we must stay in bed because we have flu, we feel like a victim of symptoms (e.g., headaches, muscle pain, chills) that we can only control with rest and fever inhibitors. The illness therefore temporarily gives us a condition of suffering. Yet, because we are the victims of flu, we also temporarily receive a number of advantages handed out to us (e.g., we do not have to work and people around us take extra care of us). This “illness benefit” is an aspect of the satisfaction that symptoms carry with them.
- 2.
Note that other pioneers from psychology, such as William James, William Stern, Lev Vygotski, and Leon Festinger, have also made a similar distinction (Marecek 2003).
- 3.
The entire dream goes as follows: “A large hall—numerous guests, whom we were receiving. -Among them was Irma. I at once took her on one side, as though to answer her letter and to reproach her for not having accepted my ‘solution’ yet. I said to her: ‘If you still get pains, it’s really only your fault.’ She replied: ‘If you only knew what pains I’ve got now in my throat and stomach and abdomen—it’s choking me’—I was alarmed and looked at her. She looked pale and puffy. I thought to myself that after all I must be missing some organic trouble. I took her to the window and looked down her throat, and she showed signs of recalcitrance, like women with artificial dentures. I thought to myself that there was really no need for her to do that.—She then opened her mouth properly and on the right I found a big white patch; at another place I saw extensive whitish grey scabs upon some remarkable curly structures which were evidently modelled on the turbinal bones of the nose.—I at once called in Dr. M., and he repeated the examination and confirmed it. … Dr M. looked quite different from usual; he was very pale, he walked with a limp and his chin was clean-shaven. … My friend Otto was now standing beside her as well, and my friend Leopold was percussing her through her bodice and saying: ‘She has a dull area low down on her left.’ He also indicated that a portion of the skin on the left shoulder was infiltrated. (I noticed this, just as he did, in spite of her dress.). … M. said ‘There’s no doubt its an infection, but no matter; dysentery will supervene and the toxin will eliminated.’ … We were directly aware, too, of the origin of her infection. Not long before, when she was feeling unwell, my friend Otto had given her an injection of a preparation of propyl, propyls … propionic acid … trimethylamin (and I saw before me the formula for this printed in heavy type). … Injections of that sort ought not to be made so thoughtlessly. … And probably the syringe had not been clean” (Freud 1900, p. 107).
- 4.
These are normally part of the formation process for psychoanalysts and psychotherapists. Lacan indicates that the purposes of a personal psychoanalysis for a psychoanalyst (sometimes called “didactical analysis”) consist of learning to recognize and conquer the “alienation in relation to oneself”—aliénation à vous-même (Lacan 1956b, p. 161). The idea of “alienation in relation to oneself” points to an obstinate hanging-on to the image of oneself; to ideas, values … in relation to others. Whoever puts the image of oneself as central has the tendency to also treat this own self-image as the standard to judge others, for example when one makes a judgment about what is normal and what is not. A personal psychoanalysis has the objective of enabling the candidate-psychoanalyst to leave behind his blindness and deafness, so that in the clinical work one learns to listen to what others actually say: “if didactical psychoanalysis makes sense, it is to make you hear yourself respond to the subject, so that you know what he tells you” (Lacan 1956b, p. 161).
- 5.
Lacan (1975, p. 42) suggests that we should talk about super-audition instead of supervision. After all, what is central in this clinical activity is listening and speaking and not so much looking and being looked at.
- 6.
Sometimes work discussions are referred to with the notion intervision. “Intervision” is, however, a broader term that is used for groups in which intercollegial discussion is central, but in which one does not always work with a discussion leader (Hendriksen 2009).
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Vanheule, S. (2017). Working with Clinical Case Formulations: Methodological Considerations. In: Psychiatric Diagnosis Revisited. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-44669-1_5
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